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Reduction in Pediatric Identification Band Errors

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Aims

  • Reduce by half the pediatric patient identification band error rate, defined as absent, illegible or inaccurate ID band, across a quality improvement learning collaborative of hospitals in one year.
Example Project Measures

​Measure Name & Description ​How Calculated
Aim 1
​% reduction in ID bank failure
rate (Process)
Failure is defined as an absent,
illegible or inaccurate ID band

Target Population:
Patients admitted to pediatric medical-surgical, pediatric intensive care and neonatal intensive care units
Numerator:
# of patients audited with ID band errors
Denominator:
# of all patients audited

Participants

This was a quality improvement collaborative of pediatric hospitalist and their nursing and quality improvement colleagues who sought to apply the general improvement model developed and implemented by Paul D. Hain, MD, FAAP and colleagues at the Monroe Carell Jr. Children's Hospital at Vanderbilt (MCJCHV) across 6 hospitals to reduce pediatric patient ID band error rates.

The hospitalist project leader was responsible for:

  • The physician at each participating institution was responsible for:
    • Overall leadership at the hospital level,
    • Data integrity review and submission monthly,
    • Local survey deployment and analysis to inform gap; and
    • Implementation of improvement strategies.
  • Sharing lessons learned and problem-solving with other participating physicians through monthly conference calls and e-mail.
Project Design

A baseline prevalence measurement was taken at each hospital between September 2009 and April 2010 followed by prevalence audits as often as four times monthly through September 2010. Those audits included night, day and weekend assessments. Each of the hospitals contributed data for a minimum of six and a maximum of 13 months, and all participated for the final five months (from May 2010 to September 2010). The overall design of the improvement project included:

  • Preparatory work: The hospital assessed its’ current state to inform the barriers/gaps at the local institution level with a survey (as described below).
  • Survey: To assist each hospital in understanding its pre-existing assumptions around ID bands, a survey originally developed at Monroe Carell Jr. Children’s Hospital at Vanderbilt (MCJCHV) was provided to each institution to assess attitudes and barriers to correct patient ID band placement and maintenance local to the organization.
  • 6 to 13-month testing phase: During the test phase, each hospital committed to submitting data on observed ID band practices and percentages. The physician also created run charts to share with the collaborative (aggregate data represented by each of six hospitals).
  • Monthly conference calls: During each call, hospitals shared their current data and lessons learned, posed problems and sought the counsel of the collaborative for resolution.  Hospitals used consistent staff and patient educational materials, shared collaborative results with their respective frontline staffs, and shared ID band alternatives for particularly vulnerable populations.
  • Access to QI Material: Each participant had the opportunity to learn overall approach to rapid cycle performance improvement, development of key driver diagrams, change management, data integrity, data analysis and collaborative learning.
  • Interventions:

    The interventions included:
  • Run charts transparently reported failure data for each hospital and collaborative overall;
  • ID bands were verified at nursing bedside handoff;
  • Patients and families engagement in patient identification and the purpose of ID band; Hospital/unit education about why accurate patient ID bands matter;
  • A sense of urgency was created using storytelling- examples of wins and failures;
  • Voluntary event reporting systems to catch errors or patients without bands in place;
  • For some patient populations or hospitals, selection of new ID bands (softer) was critical to acceptance;
  • With audit failures, the bedside RN was asked “why” and a fix occurred immediately;
  • Leadership engagement;
  • The topic was discussed on safety walkrounds.
Project Data Collection included:

  • Direct Observation Audits: Participating hospital staff audited to identify ID band failure 4 times monthly.
  • Attitudes and Barriers Survey: This survey originally developed at MCJCHV was provided to each institution to assess attitudes and barriers to correct patient ID band placement and maintenance local to the organization.
  • Monthly Run Charts: The 4 times monthly data were aggregated into monthly run charts for each participating hospital.

Project Resources:

Survey tool
Patient Education Materials
Audit sheet to collect data
Data spreadsheet to aggregate data


Results:
The collaborative audited 11,377 patients for ID band errors between September 2009 and September 2010. The ID band failure rate decreased from 17% to 4.1% (77% relative reduction).

Reduction in Pediatric Identification Band Errors: A Quality Collaborative (Pediatrics, May 2012)

A special thanks to our Reduction in Pediatric Identification Band Errors: A Quality Collaborative Lead Experts:

  • Shannon Connor Phillips, MD, MPH, FAAP
  • Michele Saysana, MD, FAAP
  • Sarah Worley, MS
  • Paul D. Hain, MD, FAAP
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